Surgical repair kit and its method of use

ABSTRACT

A suture passer including a longitudinally-extending hollow cannula having a central passage slidingly receivable of a surgical suture; a manually graspable handle connected to the hollow cannula for manipulation thereof, the handle having an upper surface; first guide means, connected to the upper surface of the handle, proximate a distal end of the handle, for releasably, guidingly holding the surgical suture; and second guide means, connected to the upper surface of the handle, proximate to the first guide means, for releasably, guidingly holding the surgical suture. The suture passer can be provided in a kit, for use in the suturing of internal tissue, along with a cannula bender, various hollow surgical needles and surgical suture material. The suture passer finds particular use in the suturing of internal tissues which are at least partially accessible through a body cavity, e.g. arthroscopic surgery.

CROSS REFERENCE TO RELATED APPLICATION

[0001] This application is a continuation-in-part of pending prior U.S.patent application Ser. No. 09/111,237, filed Jul. 7, 1998 by Kwan-HoChan for SURGICAL REPAIR KIT AND ITS METHOD OF USE, which document ishereby incorporated herein by reference.

[0002] This application also claims the benefit of pending prior U.S.Provisional Patent Application Serial No. 60/101,162, filed Sep. 21,1998 by Kwan-Ho Chan for SUTURE PASSER AND RETRIEVER SYSTEM, whichdocument is also hereby incorporated herein by reference.

FIELD OF THE INVENTION

[0003] The present invention relates to medical devices for performingsurgery and a surgical repair kit containing the same. Moreparticularly, the present invention is directed to a surgical repair kituseful for performing arthroscopic meniscal repairs and other surgicalprocedures.

BACKGROUND OF THE INVENTION

[0004] Menisci are tough rubbery “C” shaped cartilage cushions that areattached by ligaments to the top plateau of the tibia. They prevent thesurfaces of the tibia and femur from grinding against each other and actas shock absorbers in the knee.

[0005] Menisci are also located in the shoulder, generally known aslabrum.

[0006] Meniscal tears are a common problem, especially among amateur andprofessional athletes. The most common meniscus injury occurs in theknee. Each year, tens of thousands of people suffer meniscal tears,particularly in or at the site of one or both knees. If these tears arenot repaired, there may be a progressive deterioration of the cartilage,leading to the painful rubbing and wearing of bones which had previouslybeen covered by cartilage. This, in turn, leads to inflammatorysynovitis, arthritis and other debilitating ailments. Consequently, atleast 30,000 to 40,000 meniscal excisions or repairs are performed tothe knee and shoulder each year.

[0007] Men and women between the ages of 18 and 45 experience themajority of meniscal tears, usually during athletic activity, such aswhen twisting, cutting, pivoting, decelerating or when being tackled.When torn, the meniscus may have a longitudinal, horizontal or radial(“parrot beak”) tear.

[0008] The damaged meniscus may be diagnosed with the assistance or useof magnetic resonance imaging (MRI) and/or an arthroscopic examination.Arthroscopy enables a surgeon to look into the joint using a miniaturevideo camera. In many cases, torn fragments of the meniscus are removedarthroscopically. In other cases, a small tear at the periphery of themeniscus, with a very swollen knee joint, may be treated by draining thejoint, temporarily restricting the use of the knee, and slowly havingthe patient begin rehabilitative exercises.

[0009] However, in still other cases, the tears in the meniscus dorequire surgical repair, normally by sewing the torn sections of themeniscus together. The use of the arthroscope greatly aids in thesurgical repair of the meniscus by allowing the surgeon to bettervisualize the small areas between which the torn meniscus lies. Thearthroscope enables the surgeon to visualize the interior of the jointand to perform surgery through small puncture holes without having toopen the joint as has been done in the past.

[0010] A number of surgical tools have been developed to assist insuturing. In some cases these tools have been developed for use inarthroscopic and/or endoscopic surgery.

[0011] In addition to the foregoing, many surgical procedures arecurrently performed on the shoulder.

[0012] More particularly, a group of four muscles around the shoulderjoint is called the rotator muscles of the shoulder. The tendonousportion of the muscles that insert into the bony tuberosities of thehumeral head is known as the rotator cuff. The rotator cuff isfrequently torn at or close to its bony insertion due to trauma or dueto degenerative changes associated with aging. Weakness and pain areindications for the surgical repair of rotator cuffs. The surgicalprocedure consists of re-attachment of the rotator to its bony bed.

[0013] Another type of tear in the shoulder that requires attentionrelates to instability of the shoulder joint after the shoulder has beenpreviously dislocated. The instability is the result of tearing of thejoint capsule and its labrum (a fibrocartilaginous structure) from theanterior aspect of the glenoid. This deficiency is commonly known as aBankart lesion. One method to correct the instability associated with aBankart lesion is to re-attach the torn capsule and labrum to bone onthe anterior aspect of the glenoid.

[0014] Both of the above procedures involve re-attaching soft tissues tobone. The arthroscope enables the surgeon to visualize the interior ofthe joint and to perform surgery through small puncture holes withouthaving to open the joint as has been done in the past. Improvements ininstrumentation and in suture anchors have made it possible for surgeonsskilled in arthroscopy to perform the above surgical proceduresarthroscopically.

[0015] The basic steps in arthroscopic rotator cuff repairs andarthroscopic Bankart repairs involve embedding a suture anchor into abony bed, passing a suture through the soft tissue and tying the softtissue to the suture anchor, thus coapting the torn tissue to the bonybed. At other times torn or lax tissues are repaired or tightened bypassing sutures through two points in the soft tissue, and then tyingthe sutures together.

[0016] U.S. Pat. No. 2,808,055 (Thayer) discloses a surgical stitchinginstrument which accommodates a bobbin of suture material and includesmeans to feed the suture material to a needle. A slidable thread-movingmember is provided for advancing the suture material through the needle.

[0017] U.S. Pat. No. 3,476,114 (Shannon et al.) discloses a ligatingimplement comprising an elongated instrument through which a ligaturepasses to form a loop at one end with a disc. The disc provides a meanswhereby the loop may be drawn tight about a severed vessel or the like.

[0018] U.S. Pat. No. 3,476,115 (Graeff et al.) discloses a ligatingimplement as in Shannon et al., and includes severing means to preventoverstressing of the locking disc during tightening of the noose.

[0019] U.S. Pat. No. 4,493,323 (Albright et al.) discloses a suturingdevice and a method for its use in arthroscopic surgery. The suturingdevice comprises an elongated tube and plunger which are used to holdand advance a pair of needles united by a length of suture material.

[0020] U.S. Pat. No. 4,641,652 (Hutterer et al.) discloses an applicatorfor tying sewing threads which comprises a helical tubular coilconnected to a shaft having an axial passage. A catcher loop isextendable through the shaft to catch a sewing thread inserted manuallyinto the coil passage.

[0021] U.S. Pat. No. 4,935,027 (Yoon) discloses surgical instruments andmethods for effecting suturing of tissue controlled from a positionremote from the suture site. The invention provides for the continuousfeeding of suture material through opposed forcep jaw members betweenwhich the tissue segments are interposed.

[0022] U.S. Pat. No. 5,112,308 (Olsen et al.) discloses a medical devicefor and a method of endoscopic surgery. The device includes a dilatorhaving a tapered end and a central passage which accommodates aguidewire for directing the dilator. This device does not include anymeans whereby the guidewire may be secured to the dilator or otherwisemanipulated in conjunction therewith.

[0023] U.S. Pat. No. 4,779,616 (Johnson) discloses a method for snaggingan end of a surgical suture during arthroscopic surgery, comprisingdeploying a distal end of a cylindrical cannula adjacent to the end ofthe suture within the body and passing a resilient loop through thecannula to snag the suture.

[0024] U.S. Pat. Nos. 4,890,615, 4,923,461 and 4,957,498 (Caspari etal.) disclose a suturing instrument and method of use in arthroscopicsurgery. The suturing instrument includes a hollow needle forpenetrating tissue to be sutured within the body while the tissue isclamped between relatively movable jaws and a suture feed mechanism forfeeding suture material through the hollow needle. The jaws can beopened and the suturing instrument withdrawn from the body, pulling thefree end segment of the suture material with the instrument.

SUMMARY OF THE INVENTION

[0025] It is an object of the present invention to provide a surgicalrepair kit. In particular, it is an object of the present invention toprovide a surgical repair kit which is particularly suited for therepair of torn menisci.

[0026] It is another object of the present invention to provide a suturepasser having means for positioning of the suture.

[0027] It is another object of the present invention to provide aparallel needle guide to allow for an easier and more successfulplacement of a second needle in close proximity to a first needle thathas been previously inserted in the area of a tissue tear.

[0028] Another object of the present invention is to provide a modularsuture passer assembly of the sort comprising a handle and a cannula,wherein the handle is adapted to releasably and lockingly hold thecannula for manipulation by a surgeon so that a length of suture may bepassed through tissue.

[0029] Still another object of the present invention is to provide asurgical kit for use in passing a length of suture through tissue,wherein the kit comprises a handle and various interchangeable cannulas,with each cannula being adapted to be releasably and lockingly held bythe handle during a surgical procedure.

[0030] Yet another object of the present invention is to provide asurgical cannula having a sharp distal tip which is adapted to piercetissue.

[0031] And another object of the present invention is to provide asurgical cannula having a sharp distal tip which is adapted to piercetissue while at least one strand of suture extends out of the cannula'ssharp distal tip, wherein the sharp distal tip of the cannula isspecially configured so as to minimize the possibility of damaging orsevering the suture during the tissue-piercing operation.

[0032] Still another object of the present invention is to provide amodular suture passer assembly which is relatively simple to manufactureand relatively easy to use.

[0033] Yet another object of the present invention is to provide a newmethod for passing suture through tissue.

[0034] While the present invention is primarily concerned with therepair of torn menisci, the repair kit, the parallel needle guide, andthe suture passer may be used in other surgical procedures, e.g., forsuturing internal tissue at least partially accessible through a bodycavity.

[0035] The invention also is suitable for various shoulder surgeryrepairs such as a Bankart repair and a rotator cuff repair, and otherarthroscopic and laparoscopic procedures.

[0036] The suture passer of the invention comprises alongitudinally-extending hollow cannula having a central passageslidingly receivable of a surgical suture and a manually graspablehandle connected to the hollow cannula for manipulation thereof. Thesuture passer has a first guide means connected to an upper surface ofthe handle, proximate to a distal end of the handle, for releasably,guidingly holding the surgical suture, and a second guide meansconnected to the upper surface of the handle, proximal to the firstguide means, for releasably, guidingly holding the surgical suture.

[0037] In one embodiment of the invention, the hollow cannula isconnected to the upper surface of the handle and the hollow cannulaterminates at a rearward opening between the first and second guidemeans.

[0038] In another embodiment of the invention, the hollow cannula isreceived within a bore formed in the handle, with the bore terminatingat an opening in the upper surface of the handle between the first andsecond guide means.

[0039] The guide means may be loops which are either parallel ortransverse to the longitudinally-extending hollow cannula. In analternative embodiment, the second guide means may consist of aplurality of bent fingers lying in parallel planes.

[0040] The guide means serve as means about which the suture is passedso it may be manipulated longitudinally with respect to the cannula. Thediameter of the central passage of the cannula is such that the tip of aspinal epidural or similar needle into which the suture is directed mayfit into the cannula and is large enough to allow the sliding passage oftwo surgical sutures (i.e., the two limbs of a single surgical suture).

[0041] In the method of use, the suture passer is used in surgicalmanipulations, and in particular meniscal repairs or other arthroscopicprocedures, to direct a suture within a joint space with a greaterdegree of precision than available by current methods.

[0042] When the two limbs of a surgical suture are within the cannula,the guide means can function to separate the two limbs. Separation ofthe two limbs of the surgical suture allows independent manipulation ofthe suture limbs. Digital manipulation of the surgical suture betweenthe first and second guide means causes longitudinal passage of one limbof the surgical suture within the cannula, i.e., friction between thedigit and the said suture will cause the said suture to slide along thetop surface of the handle, into or out of the cannula, when manipulateddigitally.

[0043] In one surgical repair kit formed in accordance with the presentinvention, the kit comprises a suture passer, as previously described,at least two surgical needles of predetermined length and at least onestylet for each surgical needle. Preferably, the surgical repair kitincludes three surgical needles, with one of the surgical needles havinga length greater than that of the other needles.

[0044] In one preferred embodiment, the suture passer is provided with ametal cannula, and the surgical repair kit includes a cannula bender forbending the metal cannula in a desired manner. The cannula bendercomprises a base and a pair of upwardly-stepped, symmetrical bolsterspositioned on top of the base, allowing the cannula to be bent to theright or to the left, each step of each bolster having a predeterminedradius of curvature wherein the radius of curvature of each step issmaller than the radius of curvature of the step immediately below.

[0045] Additionally, in one surgical repair kit formed in accordancewith the present invention, the kit may further include a parallelneedle guide for guiding the surgical needles for desired placementrelative to each other. The parallel needle guide comprises at leastthree longitudinally-extending, hollow tube-shaped units longitudinallyadhered to each other, in a plane, parallel to one another, each of thetube-shaped units slidingly receivable of a surgical needletherethrough.

[0046] The present invention also provides methods for the suturing ofinternal tissue which is at least partially accessible through a bodycavity.

[0047] A first method comprises the steps of:

[0048] (a) providing at least one suture having a first limb and asecond limb;

[0049] (b) providing a suture passer comprising alongitudinally-extending hollow cannula having a distal opening, aproximal opening and a central passage slidingly receivable of asurgical suture;

[0050] (c) introducing the distal end of the cannula into a body cavityat least partially accessing internal tissue to be sutured;

[0051] (d) identifying a first insertion site for passing a first limbof a suture through the internal tissue to be sutured;

[0052] (e) inserting a first hollow needle through the first insertionsite, the hollow needle extending from outside the body through thefirst insertion site into the body cavity;

[0053] (f) identifying a second insertion site for passing a second limbof the suture through the internal tissue to be sutured;

[0054] (g) inserting a second hollow needle through the second insertionsite, the hollow needle extending from outside the body through thesecond insertion site into the body cavity;

[0055] (h) passing the second limb of the suture through the firsthollow needle into the distal opening of the cannula until it exits theproximal opening of the cannula;

[0056] (i) feeding the second limb of the suture back into the cannulathrough the proximal opening;

[0057] (j) passing the second limb of the suture through the hollowcannula into the second hollow needle until it exits the needle externalof the body;

[0058] (k) drawing the suture through the cannula into the body cavity;

[0059] (l) removing the first and second needles by drawing themoutwardly of the body cavity;

[0060] (m) tying the limbs of the suture; and

[0061] (n) repeating steps (d)-(m) until a surgically sufficient numberof sutures have been tied.

[0062] A second method comprises the steps of:

[0063] (a) providing at least one suture having a first limb and asecond limb;

[0064] (b) providing a suture passer comprising alongitudinally-extending hollow cannula having a distal opening, aproximal opening and a central passage slidingly receivable of asurgical suture;

[0065] (c) loading the suture passer with a surgical suture such that anend of the first limb of the suture and an end of the second limb of thesuture each protrude from the distal end of the cannula;

[0066] (d) introducing the distal end of the cannula into a body cavityat least partially accessing internal tissue to be sutured;

[0067] (e) identifying a first insertion site for passing the first limbof the suture through the internal tissue to be sutured;

[0068] (f) inserting a first hollow needle through the first insertionsite, the hollow needle extending from outside the body through thefirst insertion site into the body cavity;

[0069] (g) identifying a second insertion site for passing a second limbof the suture through the internal tissue to be sutured;

[0070] (h) inserting a second hollow needle through the second insertionsite, the hollow needle extending from outside of the body through thesecond insertion site into the body cavity;

[0071] (i) introducing the end of the first limb of the suture into thefirst hollow needle until it exits the first hollow needle outside thebody;

[0072] (j) introducing the end of the second limb of the suture into thesecond hollow needle until it exits the second hollow needle outside thebody;

[0073] (k) drawing the suture through the cannula into the body cavity;

[0074] (l) removing the first and second hollow needles by drawing themoutwardly of the body cavity;

[0075] (m) tying the limbs of the suture; and

[0076] (n) repeating steps (c)-(m) until a surgically sufficient numberof sutures have been tied.

[0077] In a further modification of the invention, the suture passer maybe formed in a modular fashion so that a variety of different cannulascan be attached to its handle. These cannulas may be blunt or sharplypointed, and they may be straight or curved, as required for aparticular surgical procedure. In this form of the invention, the suturepasser's handle includes a female lock portion which is configured toreceive and lockingly hold a cannula which is provided with acorresponding male lock portion.

[0078] In a preferred form of the modular suture passer, each of theinterchangeable cannulas is provided with a radial fin which is attachedto the cannula adjacent to the cannula's proximal end. This fin includesa main portion and a tab portion. The tab portion of the fin extendsproximally from the main portion of the fin. The tab portion of the finincludes an upper tab projection defining an upper, distally-facing tabshoulder and a lower tab projection defining a lower, distally-facingtab shoulder. The tab portion's upper and lower tab projections arelocated between the main portion of the fin and the proximal end of thetab portion. The tab portion's upper and lower tab shoulders are alignedwith one another.

[0079] The modular handle includes first and second suture guide meansgenerally of the sort disclosed above.

[0080] The modular handle also comprises a first bore which extendsproximally and axially into the handle from the distal end thereof. Thefirst bore includes a stop at its proximal end. The first bore is sizedand positioned so that it can receive the proximal portion of a selectedcannula, with the proximal end of the cannula's central lumen openingonto the upper surface of the handle between the first and second guidemeans when the cannula's proximal end is in engagement with the firstbore's stop. A slot extends proximally and axially into the handle fromthe distal end thereof. The slot communicates with the handle's firstbore and is sized to receive the main portion of the fin of a cannulawhen that cannula is mounted to the handle.

[0081] A cavity is formed in the handle immediately proximal to theslot. This cavity is sized to receive the tab portion of a cannula whenthat cannula is mounted to the handle. An upper sidewall projectionextends inwardly into the cavity from one of the sidewalls of thecavity, and a lower sidewall projection extends inwardly into the cavityfrom the same sidewall of the cavity. The upper sidewall projectiondefines an upper, proximally-facing sidewall shoulder, and the lowersidewall projection defines a lower, proximally-facing sidewallshoulder. The upper and lower sidewall shoulders are aligned with oneanother. The upper and lower sidewall projections are located such thatas the tab portion of a given cannula enters the handle's cavity, thecannula's upper and lower tab projections will snap over and lockinglyengage the handle's upper and lower sidewall projections when thecannula is fully inserted into the handle's first bore. In particular,when the assembly is in this locked condition, the cannula'sdistally-facing upper tab shoulder will engage the handle'sproximally-facing upper sidewall shoulder, and the cannula'sdistally-facing lower tab shoulder will engage the handle'sproximally-facing lower sidewall shoulder.

[0082] When a given cannula has been mounted to the handle in theforegoing manner, rotational movement of the cannula relative to thehandle is precluded by the engagement of the cannula's main fin portionwith the sidewalls of the handle's slot. In addition, axial movement ofthe cannula relative to the handle is precluded (i) in the proximaldirection by the engagement of the proximal end of the cannula with thestop located at the proximal end of the handle's first bore, and (ii) inthe distal direction by the engagement of the cannula's twodistally-facing tab shoulders with the handle's two proximally-facingsidewall shoulders.

[0083] The handle of the modular suture passer also includes means forreleasing a cannula from its locking engagement with the handle. Moreparticularly, when a given cannula has been mounted to the handle in theforegoing manner, the proximal-most portion of the cannula's tab portionwill extend proximally into a second bore formed in the handle.

[0084] The second bore extends axially through the handle, from theproximal end of the handle's cavity to the proximal end of the handle. Arelease rod is positioned within the second bore for reciprocal movementtherein, between (i) a proximalmost position in which the release rod iswithdrawn from engagement with a cannula mounted to the handle, and (ii)a distalmost position in which the release rod is in engagement with acannula mounted to the handle. Spring means are provided for yieldablybiasing the release rod into its proximalmost position. The release rodhas a beveled distal end terminating in a drive surface. A cannula isdismounted from the handle by urging the release rod from itsproximalmost position to its distalmost position. As the release rodbegins to move from its proximalmost position to its distalmostposition, the rod's beveled distal end will first engage the proximalend of the cannula's tab portion and deflect the tab portion laterally,whereby the cannula's two distally-facing tab shoulders will bedisengaged from the handle's two proximally-facing sidewall shoulders.Thereafter, as the release rod continues to move from its proximalmostposition to its distalmost position, the release rod's drive surfacewill engage the proximal end of the cannula's tab portion, whereby theentire cannula will be driven distally so that the cannula's two tabprojections will clear the handle's two sidewall projections. This willunlock the cannula from the handle. The cannula may thereafter bemanually withdrawn from the handle by pulling the cannula in a distaldirection.

[0085] In another form of the invention, there is provided a cannulahaving a proximal end, a distal end, and a passage therethrough,comprising a plurality of hollow cylinders that are interconnected.

[0086] In another form of the invention, there is provided an apparatusfor receiving and passing one or more sutures, one or more tools, andcombinations thereof, comprising a handle having a proximal end and adistal end; and a cannula mounted on the distal end of the handle;wherein the proximal end of the handle is configured to receive one ormore sutures for passage into the cannula.

[0087] In another form of the invention, there is provided an apparatusfor receiving and passing one or more sutures, one or more tools, andcombinations thereof, comprising a handle; and a suture guide, having asuture entrance, mounted on said handle; wherein the suture entrance isobservable from a transverse projection thereof.

[0088] In another form of the invention, there is provided an apparatusfor receiving and passing one or more sutures, one or more tools, andcombinations thereof, comprising a handle having a first proximal end; asuture guide, having a second proximal end, mounted on the handle;wherein the second proximal end is distal of the first proximal end.

[0089] In another form of the invention, there is provided an apparatusfor receiving and passing one or more sutures, one or more tools, andcombinations thereof, comprising a handle; a cannula mounted on thehandle; and a proximal suture guide mounted on the handle; the cannulaand the proximal suture guide defining a gap therebetween; wherein thegap is optimized to provide maximum suture exposure with limited suturebuckling during advancement of the suture.

[0090] In another form of the invention, there is provided an apparatusfor receiving and passing one or more sutures, one or more tools, andcombinations thereof, comprising a handle having a shape thatfacilitates orientation thereof.

[0091] In another form of the invention, there is provided an apparatusfor receiving and passing one or more sutures, one or more tools, andcombinations thereof, comprising a handle; and a cannula mounted on thehandle; the handle having a surface for slidingly advancing suture intothe cannula; wherein the cannula is aligned with the surface.

[0092] In another form of the invention, there is provided an apparatusfor receiving and passing one or more sutures, one or more tools, andcombinations thereof, comprising a cannula having a distal end; whereinat least a portion of the distal end is configured to drive a sutureagainst tissue without severing the suture.

[0093] In another form of the invention, there is provided an apparatusfor receiving and passing one or more sutures, one or more tools, andcombinations thereof, comprising a handle including a suture retainer.

[0094] In another form of the invention, there is provided an apparatusfor receiving and passing one or more sutures, one or more tools, andcombinations thereof, comprising a handle; and a cannula, configured toreceive the one or more tools, mounted on the handle.

[0095] In another form of the invention, there is provided a sutureretrieving tool comprising a handle having a distal end and a proximalend; a cannula having a distal end and a proximal end, the proximal endof the cannula being attached to the distal end of the handle, and thecannula having a slot opening on its distal end and extending toward itsproximal end; a hook retriever having a distal end and a proximal end,the distal end being configured in the shape of a hook, and the proximalend being attached to the distal end of the handle, the hook retrieverhaving a bend intermediate of its distal and proximal ends; and a sleevehaving a distal end and a proximal end, the sleeve being disposed aroundthe hook retriever and within the cannula, the sleeve being slidablyattached to the handle such that (1) the sleeve can be positioned in afirst retracted position wherein the distal end of the sleeve isdisposed proximal to the bend, such that the hook retriever can extendout the slot in the cannula, and (2) the sleeve can be positioned in asecond extended position wherein the distal end of the sleeve isdisposed distal to the bend, such that the hook retriever will bewithdrawn inboard of the slot.

BRIEF DESCRIPTION OF THE DRAWINGS

[0096]FIG. 1 is a side view of the suture passer;

[0097]FIG. 2 is a top view of another embodiment of the suture passer;

[0098]FIG. 3 is a side view of the suture passer of FIG. 2;

[0099]FIG. 4 is a frontal view of the handle of the embodiment of thesurgical suture passer of FIG. 3;

[0100]FIG. 5 is a cross-section of the handle of the surgical suturepasser;

[0101]FIG. 6 is a side view of another embodiment of the surgical suturepasser;

[0102]FIG. 7A is a side view, and FIG. 7B is a top view, of anotherembodiment of the surgical suture passer;

[0103]FIG. 8A is an enlarged side view of a tip of a spinal needle, andFIG. 8B is an enlarged side view of a tip of an epidural needle;

[0104]FIG. 9 is a side view of a parallel needle guide;

[0105]FIG. 10 is a frontal view of a parallel needle guide;

[0106]FIG. 11 is a side sectional view of a needle containing a stylet;

[0107]FIG. 12 is a frontal view of a cannula bender;

[0108]FIG. 13 is a frontal view illustrating the use of the cannulabender;

[0109] FIGS. 14-26 are cross-sectional top views at various stages of anoperation where the middle third of the meniscus is being repaired;

[0110]FIG. 27A, FIG. 27B, and FIGS. 28-31 are cross-sectional top viewsat various stages of an operation where the posterior region of themeniscus is being repaired;

[0111]FIG. 32 is a left side view of a modular suture passer formed inaccordance with the present invention;

[0112]FIG. 33 is a right side view of the modular suture passer shown inFIG. 32;

[0113]FIG. 34 is a top view of the modular suture passer shown in FIG.32;

[0114]FIG. 35 is a bottom view, with portions broken away, of themodular suture passer shown in FIG. 32;

[0115]FIG. 36 is a left side view similar to that of FIG. 32, exceptthat the modular suture passer's handle is shown in section so as toreveal how the cannula is in locking engagement with the handle;

[0116]FIG. 37 is a bottom view similar to that of FIG. 35, except thatthe modular suture passer's handle is shown in section so as to revealhow the cannula is in locking engagement with the handle;

[0117]FIG. 37A is an enlarged bottom view showing selected portions ofFIG. 37 in greater detail;

[0118]FIG. 38 is a left side view similar to that of FIG. 36, exceptthat the cannula is shown released from its locking engagement with thehandle, with the handle's release rod having moved from its proximalmostposition to its distalmost position;

[0119]FIG. 39 is a bottom view similar to that of FIG. 37, except thatthe cannula is shown released from its locking engagement with thehandle, with the handle's release rod having moved from its proximalmostposition to its distalmost position;

[0120]FIG. 39A is an enlarged bottom view showing selected portions ofFIG. 39 in greater detail;

[0121]FIG. 40 is an enlarged left side view, partially cut away, of acannula suitable for use with the modular suture passer shown in FIGS.32-39;

[0122]FIG. 41 is a rear view of the cannula shown in FIG. 40;

[0123]FIG. 42 is a top view, partially cut away, of the cannula shown inFIG. 40;

[0124]FIG. 43 is an enlarged top view of the pointed distal end of thecannula shown in FIG. 40;

[0125]FIG. 44 is an enlarged left side view, partially cut away, ofanother cannula suitable for use with the modular suture passer shown inFIGS. 32-39;

[0126]FIG. 45 is an enlarged left side view, partially cut away, ofstill another cannula suitable for use with the modular suture passershown in FIGS. 32-39;

[0127]FIG. 46 is an enlarged left side view, partially cut away, of yetanother cannula suitable for use with the modular suture passer shown inFIGS. 32-39;

[0128]FIG. 47 is an enlarged left side view, partially cut away, ofstill another cannula suitable for use with the modular suture passershown in FIGS. 32-39;

[0129]FIG. 48 is an enlarged left side view, partially cut away, of yetanother cannula suitable for use with the modular suture passer shown inFIGS. 32-39;

[0130]FIG. 49 is an enlarged left side view, partially cut away, ofstill another cannula suitable for use with the modular suture passershown in FIGS. 32-39;

[0131]FIG. 50 is an illustrative side view showing the modular suturepasser of FIGS. 32-39 adjacent to a piece of tissue, wherein a length ofsuture extends through the suture passer's cannula, and further whereinthe suture end extending out of the distal end of the cannula engagesthe handle's distal suture guide, and the suture end extending out ofthe proximal end of the cannula engages the handle's proximal sutureguide;

[0132]FIG. 51 is an illustrative side view similar to that of FIG. 50,except that the distal end of the cannula has been inserted through thepiece of tissue, carrying the length of suture with it;

[0133]FIG. 52 is an illustrative side view similar to that of FIG. 51,except that the cannula has been withdrawn from the piece of tissue,leaving a loop of suture extending through the tissue, with the sutureend extending from the distal end of the cannula having been disengagedfrom the handle's distal suture guide;

[0134] FIGS. 53-55 illustrate how a simple stitch can be establishedacross two pieces of tissue using the present invention;

[0135] FIGS. 56-58 illustrate how a suture loop can be passed across twopieces of tissue using the present invention;

[0136] FIGS. 59-61 illustrate two different ways a folded suture loopcan be passed across two pieces of tissue using the present invention;

[0137] FIGS. 62-64 illustrate how a simple stitch can be converted to amattress stitch with a suture loop using the present invention;

[0138]FIG. 65 is a side view of another embodiment of suture passer;

[0139]FIG. 66 is a top view of the embodiment of FIG. 65;

[0140]FIG. 67 is a frontal view of the handle of the embodiment of FIG.65;

[0141]FIG. 68 is a side view of an additional embodiment of suturepasser including a suture retainer;

[0142]FIG. 69 is a side view of a further embodiment of suture passerincluding a suture retainer;

[0143]FIG. 70 is a side view of yet another embodiment of suture passerincluding a suture retainer;

[0144]FIG. 71 is a side view of yet another embodiment of suture passer;

[0145]FIG. 72 is a top view of a loop retriever;

[0146]FIG. 73 is a side view of the embodiment of FIG. 72;

[0147]FIG. 74 is a top view of the suture passer of FIG. 65 receivingthe loop retriever of FIG. 72, the loop retriever being articulated intoa closed loop configuration;

[0148]FIG. 75 is a top view of the suture passer of FIG. 65 receivingthe loop retriever of FIG. 72, the loop retriever being articulated intoan open loop configuration;

[0149]FIG. 76 is a side view of a hook retriever;

[0150]FIG. 77 is a top view of the embodiment of FIG. 76;

[0151]FIG. 78 is a side view of the suture passer of FIG. 65 receivingthe hook retriever of FIG. 76, the loop retriever being articulated intoa closed configuration;

[0152]FIG. 79 is a side view of the suture passer of FIG. 65 receivingthe hook retriever of FIG. 76, the loop retriever being articulated intoan open configuration;

[0153]FIG. 80 is an enlarged side view of an alternative form of suturepasser-and-hook retriever tool, with the hook retriever being in aclosed configuration;

[0154]FIG. 81 is an enlarged top view of the suture passer-and-hookretriever tool of FIG. 80; and

[0155]FIG. 82 is an enlarged side view of the suture passer-and-hookretriever tool of FIG. 80, but with the hook retriever being in an openconfiguration.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0156] FIGS. 1-7 illustrate the meniscal suture passer 1, used for thepassage of a suture in a confined area of the body during surgery. Thesuture passer 1 comprises a longitudinally-extending hollow cannula 2having a central passage slidingly receivable of a surgical suture, anda manually graspable handle 3 connected to the hollow cannula 2 formanipulation thereof. A first guide means is connected to the uppersurface of the handle 3 for releasably, guidingly holding the surgicalsuture. A second guide means for guidingly holding the suture is alsoconnected to the upper surface of the handle 3. The second guide meansis proximal to the first guide means. The suture passer 1 in FIGS. 1-6comprises the cannula 2, the handle 3, a rearward opening 4 near thedistal end of the handle 3, a distal loop 5, and a proximal loop 6. Thedistal loop 5 serves as the first guide means, and the proximal loop 6serves as the second guide means. Distal loop 5 preferably comprises asingle turn open wire loop having a first axis of rotation of the loop,and proximal loop 6 is preferably a 1½ pigtail open wire loop having asecond axis of rotation of the loop. The loops 5, 6 are preferablyparallel to one another. In one embodiment, the wire loops 5 and 6 arepreferably perpendicular to the handle 3, with the first axis ofrotation and the second axis of rotation transverse to saidlongitudinally-extending hollow cannula 2. In another embodiment, theaxes of rotation of loops 5 and 6 are parallel to thelongitudinally-extending cannula 3. Near the distal end of the handle isthe opening 4 which leads from the handle 3 to the cannula 2. The handlepreferably is provided with gripping means, and is preferably knurled at7, so that the surgeon has a better grip on the suture passer 1.

[0157] The cannula 2 may be attached and enter through an opening at theconcentric center of the handle 3 as shown in FIG. 1. The hollow cannula2 is received within a bore 8 formed in the handle 3, with the bore 8terminating at the opening 4 in an upper surface of the handle 3intermediate the first and second guide means. In an alternativeembodiment, the cannula may be connected to the upper surface of thehandle 3, as shown in FIG. 3. In this embodiment of the invention, thereis no opening into or through the handle 3. Instead, the hollow cannula2 terminates at a rearward opening 10 between the first and second guidemeans directly on top of the handle 3. Additionally, in the embodimentof FIG. 1, the handle of the suture passer is rounded, whereas in theembodiment of FIGS. 3 and 4, the suture passer handle 3 is flattened onthe side upon which the proximal end 10 of the cannula 2 resides.Additionally, in the embodiment of FIG. 3, the distal loop 5 resides onthe cannula 2 just prior to the proximal opening 4 of the cannula 2.

[0158] The central passage of the cannula should have a diameter largeenough to allow sliding passage of two surgical suture strandstherethrough. A distal opening 11 of the cannula should also have adiameter large enough to allow engagement with the tip of a spinal orepidural needle for the purpose of passage of the suture between thecannula and the needle.

[0159] In the embodiment of FIG. 1, the cannula 2, from its distalopening 11 to the point at which it enters the handle, ranges in lengthfrom about 6.0 cm to about 20.0 cm, and more preferably is about 12.0 cmin length. The opening of the cannula 2 is preferably from about 0.08 cmto about 0.32 cm in width, and more preferably is about 0.16 cm inwidth. The wall of the cannula 2 is preferably from about 0.01 cm toabout 0.05 cm in thickness, and more preferably is about 0.0254 cm inthickness. The handle preferably has a width ranging from about 0.64 cmto about 1.28 cm, and more preferably is about 0.96 cm in width.

[0160] The wire of the wire loops as shown in FIG. 5 ranges from about0.10 to about 0.14 cm in diameter “a” and is preferably attached to thehandle by a mounting structure 12 which is about 0.1 to about 0.4 cm inheight “h”.

[0161] In the embodiment of the invention illustrated in FIG. 6, thesuture passer 1 is similar to the invention illustrated in FIG. 3;however, the cannula 2 is flush with the flattened surface of the handle1 bearing the wire loops 5 and 6. A segmented piece 13, upon which thedistal loop 5 resides, attaches the cannula 2 to the handle 3. Theproximal opening 10 of the cannula opens near the proximal side of thesegmented piece 13.

[0162] In all of the aforementioned embodiments of the meniscus suturepasser 1, the proximal loop 6 may be fitted anywhere along the length ofthe handle. However, in some cases it is preferable that the proximalloop 6 be fitted about halfway between the ends of the handle of thesuture passer.

[0163] In yet another embodiment of the invention, shown in FIG. 7A andFIG. 7B, the first guide means comprise a single turn open loop 5 lyingin a first plane, with the first plane disposed perpendicularly to thelongitudinally-extending hollow cannula, and the second guide meanscomprise a plurality of bent fingers lying in parallel planes. Theplanes are parallel to each other and are perpendicular to thelongitudinally-extending hollow cannula. The bent fingers may bealternately bent in opposite directions. As shown in FIGS. 7A and 7B,the second guide means may have 3 bent fingers 14, 15, 16.

[0164] The suture passer 1 may be made out of either plastic or metal,or a combination thereof, with the handle, loops, or cannula beingplastic, metal or any combination thereof. The cannula of the meniscalsuture passer may be semi-rigid. The cannula should be rigid enough tostabilize the inner tear of the meniscus during the insertion of thespinal or epidural needle. Additionally, if made of plastic, the cannulashould be malleable enough that it can be bent by hand without the needof a special bender. After the cannula is bent, it should not springback. Because of its malleable characteristics, the plastic material isless likely to damage the articular surface. If the suture passer isentirely made out of plastic, the entire suture passer device can beinjection molded as a single unit. If the handle is made out of plasticmaterial, the loop or the finger projections may be molded as anintegral part of the handle.

[0165] If the suture passer is made out of metal, however, the loops maybe screwed, riveted, or soldered onto the handle of the suture passer.

[0166] Frequently, surgical instruments and suturing devices must beadaptable to the environment or conditions in which they are being used.More specifically, because of the location of the menisci in theshoulder and in the knee, or because there is limited space in that partof the body being repaired for the placement of surgical tools,especially during suturing, it is frequently advisable to adjust theshape of the cannula of the suture passer or to bend the needles beingused during suturing to allow for the positioning of the instrumentsinto or through the surgical incision to allow for maximum visibility onthe part of the operating team, and to avoid crowding of the incisionarea which would hinder the operating team.

[0167] Preferably included in the surgical repair kit, when the cannulais made out of metal, is a cannula bender. The cannula bender may beused to bend the cannula without kinking the cannula.

[0168] A cannula bender 30 shown in FIGS. 12 and 13 is designed to benda cannula to a desired curvature. It is different from the existing tubeor cannula benders in that it allows the cannula be bent to variousradii of curvature. The cannula bender 30 can also bend the cannula inmore than one plane.

[0169] The cannula bender 30 consists of a base 31 with an approximatediameter of from about 1.25 cm to about 8 cm, with a preferred diameterof about 3.8 cm. The base, which is preferably curved, circular, or ovalin shape, serves as a handle by which the cannula bender is grasped. Thebase 31 may be knurled or striated to provide for a better grip.

[0170] There are symmetrical curved bolsters having steps 33, 34, 35,and 36 on top of the base. The stepped configuration provides the highersteps 34, 35 with a smaller radius of curvature. The steps range fromabout 0.6 cm to about 4 cm in height, with a preferred height of about 1cm. Two steps are illustrated, but more can be provided.

[0171] The cannula 2 is bent against the bolsters 33 or 36 to create thedesired curvature. If a greater degree of curvature is required, thecannula may be bent against the higher bolsters 34 or 35 that have asmaller radius. The symmetry of the bolsters allows the cannula to bebent to the right or to the left without having to rotate the cannulabender. This allows for a faster, easier use of the cannula bendershould the need arise during surgery.

[0172] The cannula can be bent again in a different plane by rotatingthe cannula while maintaining the cannula bender in the sameorientation. The pre-bent cannula can be contoured against the bolsterin a second plane as long as the curvature is less than the height ofthe step of the bolster.

[0173] The entire cannula does not have to be bent, if at all. Thepurpose of bending the cannula is for the convenience of the surgeon inpassing the suture to and from the needle(s) to the suture passer, andto manipulate the suture passer so as to reach an area in the cavity orjoint that would otherwise be inaccessible by a straight cannula.

[0174] In addition to the suture passer device, the surgical repair kitpreferably also contains at least two and preferably three needles.These needles can be either epidural needles or spinal needles. It ispreferred that the needles be epidural needles 18, two of which are ofthe same length, e.g., about 3.5 inches in length, and one of which islonger, e.g., about 4.75 inches in length. It is also preferred that theneedles be 18 gauge needles. As seen in FIG. 8A, a spinal needle 17 hasa beveled tip which, during repair of the meniscus, may accidentallylacerate the articular cartilage. In contrast, as seen in FIG. 8B, theepidural needle 18 has a Huber tip. With the epidural needle it iseasier to advance the needle through tough tissue by using a twistingmotion. The “rounded” tip of the epidural needle is less likely tolacerate the articular surface.

[0175] The surgical repair kit preferably comes with at least twoneedles of the same length because the needle which is inserted firstbecomes blunt after several insertions. The insertion of the second,generally longer, epidural needle is easier with the use of the parallelneedle guide 19 as shown in FIGS. 9 and 10. Longer and shorter needlesare utilized to prevent the hubs 29A of adjacent needles frominterfering with one another by staggering the hub distance from thepatient's body. The parallel needle guide 19 allows for the properalignment of the needles through which the suture will pass. Theparallel needle guide 19 is a series of at least three, and preferablyfour to five, hollow tube-shaped units 20 longitudinally adhered to eachother, one on top of the other, in a parallel formation. The opening ordiameter of each tube-shaped unit should be large enough to allow forthe passage of an 18 or 21 gauge needle therethrough. The parallelneedle guide may be made out of plastic, paper or metal. The parallelneedle guide may be made from a mold, or the individual tubes may beindividually formed and bonded to each other. Any method of forming thestructure is acceptable.

[0176] Additionally, at least one stylet, typified by the stylet 29shown in FIG. 11, is provided in the surgical repair kit for each needleincluded in the repair kit. The stylet is kept on the needle until theneedle is passed through the meniscus. This prevents the needle(s) frombeing clogged with tissue and cartilage as it is pushed through thecartilage. A needle clogged with tissue will, of course, not allow thesuture to be passed through the needle to the suture passer.

[0177] A template (not shown) is preferably included in the surgicalrepair kit. This template may be printed on the back of the surgicalrepair kit container, or it may be printed on a paper guide inside themeniscal repair kit, or it may be provided on, or as, a plastic guide.The template is used as a guide for the bending of the cannula.

[0178] Each of the items included in the surgical repair kit is sterile.Additionally, each item in the surgical repair kit is preferablyindividually packaged in sterile plastic, paper, metal foil, orcombinations thereof. The packaging should be easy to open, so that thecontents thereof are not damaged or do not fall on the operating floorwhile opening. The contents of the package and the packaging may besterilized with ethylene oxide or by radiation, or by any otherconventional method for the sterilization of packaged elements.

[0179] The surgical repair kit which includes the suture passer, atleast two surgical needles of predetermined length, and at least onestylet for each needle, may also contain an optional third needle ofgreater length than the other two needles, the parallel needle guide,and a template. If the cannula is made of metal, a cannula bender mayalso be included in the repair kit.

[0180] While the foregoing repair kit may be used for any surgery, therepair kit is extremely useful in meniscal repair.

[0181] In repairing the middle third of the meniscus, an arthroscope 37should enter through the ipsilateral portal 38, as shown in FIG. 14. Thesuture passer 1 should enter through the contralateral portal 39. Theepidural needle 18 is loaded through the hole on one end of the needleguide 19 using a one-handed technique so as to avoid accidental punctureof the surgeon's opposite hand.

[0182] There are three methods for identifying the insertion points forthe needles.

[0183] The first method is to view the meniscal tear with thearthroscope, with the synovial meniscal junction in view, and thenadvance the arthroscope to the synovial meniscal junction. The lightfrom the arthroscope will transilluminate the skin. The point ofinsertion of the epidural needle should be slightly distal to thislight.

[0184] The second method for determining where to insert the needles isto view the meniscal tear and to keep the synovial meniscal junction inview. Palpate along the joint line with the tip of a finger or ameniscal probe. The area of maximal wall motion at the synovial meniscaljunction indicates the point at which the epidural needle should beinserted.

[0185] The third method is the easiest method in determining the needleinsertion point, if the synovial meniscal junction is accessible to thesuture passer. The tip of the suture passer is pushed against thesynovial meniscal junction and the skin is palpated with the finger. Thearea of the tip of the suture passer will indicate the approximatelocation where the needle should be inserted.

[0186] The needles may be advanced with a twisting motion if difficultyis encountered in penetrating the tough meniscal tissue. As shown inFIG. 15, an inner rim 40 of a meniscal tear 41 may be buttressed withthe tip of the cannula 2 of the suture passer so as to stabilize itagainst the advancing needle 18.

[0187] Using the parallel needle guide, two epidural needles areinserted through the guide and across the meniscal tear, with a longepidural needle 42 being inserted through the needle guide at a desiredseparation distance from the shorter needle (as shown in FIG. 16). Thislonger needle is inserted through the meniscal tissue, preferably behindthe shorter needle. The stylets are removed from the needles. A sutureis passed through the “first” needle. The tip of the cannula of thesuture passer is introduced into the joint cavity through a smallincision. The distal opening of the cannula is placed at or near theopening of the needle through which the suture has been passed. Thereare areas in the joint cavity, although visible through the arthroscope,which are not accessible with a straight cannula. Consequently, prior tothe introduction of the suture passer, the cannula of the suture passermay be bent on the cannula bender. The curved cannula allows the surgeonto reach remote areas where the meniscus is being repaired.

[0188] In a preferred method for passing the suture from the cannula tothe needle, the needle, preferably an epidural needle with a Huber tip,engages the opening of the cannula (FIG. 17). The more posterior needleis advanced into the joint and the surgeon captures the tip of theneedle with the tip of the cannula. For ease of passage, it ispreferable that the cannula and needle meet at about a 15°-20° angle.The opening of the needle should be facing away from the apex ofengagement between the cannula and the needle. The suture is passeddirectly from the cannula into the tip of the needle or vice versa.

[0189] By careful manipulation, a suture 43 is fed through the needleand into the cannula. With the tip of the cannula and the needlesecurely engaged, the suture is fed (FIG. 18) into the hub of the needleuntil it exits the proximal end of the cannula at the handle of thesuture passer. It is advisable to pull the suture three-quarters of theway through. The suture is then looped onto the distal guide and isthreaded back into the cannula. The suture is then engaged onto theproximal guide (FIG. 19).

[0190] The first needle is removed, and with the two limbs of the sutureheld separately by the proximal and distal guides, one limb of thesuture is advanced by sliding the suture with the index finger over thetop surface of the handle so that the suture emerges from the tip of thecannula (FIG. 20). The suture, via the suture passer, is now fullycontrollable with one hand. The tip of the second needle and the tip ofthe cannula are brought into close proximity and the suture is passedfrom the loaded suture passer into the opening of the second needle andthrough the second needle. The suture is advanced until it exits fromthe hub of the second needle (FIG. 21). The second needle is partiallyremoved so that the tip of the second needle is buried within the softtissue 44 (FIG. 22). The suture is disengaged from the guides on thehandle of the suture passer.

[0191] While grabbing both ends of the suture, the suture is pulledthrough the cannula into the joint 45 (FIG. 23). With the second needlestill in place, a stab incision is made along the shaft of the secondneedle down to the level of a joint capsule 47 but not beyond (FIG. 24).The second needle is removed and the soft tissue is dissected all theway down to the joint capsule by spreading the soft tissue with a pairof small forceps 48 (FIG. 25). The other limb of the suture is thenretrieved through this “stab incision” with a meniscal probe 49 (FIG.26), and the sutures are tied after all of the sutures have been putinto place.

[0192] For a meniscal tear in the more posterior position, the straightcannula can enter through the ipsilateral portal to reach the posteriorhorn of the meniscus (FIG. 27A). The cannula can also be contoured toreach a specific zone of the meniscus with the use of the cannula benderand the template for the various zones (FIG. 27B).

[0193] During repair of the meniscus, if the tip of the cannula cannotengage the tip of the needle during initial passage of the suture, thesuture may be fed through the posterior needle into the joint. Thesuture may then be retrieved with a snap or a suture retriever 50 (FIG.28). The first needle is removed and the suture is fed into the cannulain a retrograde direction (FIG. 29). The cannula is advanced into thejoint along the suture. The suture is then looped onto the distal guideand threaded back into the cannula until it reaches the tip of thecannula. The suture is then engaged onto the proximal guide (FIG. 30).

[0194] The suture is then advanced into the tip of the second needleunder arthroscopic visualization (FIG. 31). The suture is advanced untilit exits from the hub of the second needle. The second needle isslightly pulled back so that the tip of the needle is buried within thesoft tissue. The suture is disengaged from the guides on the handle ofthe suture passer and the suture is pulled through the cannula into thejoint.

[0195] The suture passer can also be used to pass the suture from thesuture passer to the hollow needles, instead of vice versa. The suturepasser is loaded with a suture so that the suture engages the first andsecond guide means, with the “beginning” and “terminal” ends of thesuture protruding from the distal opening of the hollow cannula. Thebeginning end of the suture is fed from the distal opening of the hollowcannula through the opening of the first hollow needle until it exitsthe first hollow needle. The terminal end of the suture is passed fromthe distal opening of the hollow cannula through the opening of thesecond hollow needle until it exits the second hollow needle. The sutureis then completely disengaged from the suture passer, the suture passeris removed, both hollow needles removed, and the suture is tightened andtied.

[0196] By maneuvering the tip of the needle with one hand and thecannula in the other when both tips are in close proximity, the suturemay be advanced.

[0197] In another method, the suture protrudes from the cannula by about½ to 1 centimeter. By manipulating the tip of the cannula with the tipof the needle, one can engage the suture into the tip of the needle andadvance the suture.

[0198] An arthroscopic video camera may be used to visualize thesuturing. The surgeon manipulates the suture preferably while viewing avideo monitor connected to the camera.

[0199] A recommended suture for use is the Ethicon “O” PDS suture. Thelength of the suture should be at least 27 inches, and preferably 36inches, in length. With other types of monofilament suture, the strandtends to be curled when removed from the packaging. It is necessary tostraighten out the suture prior to use, as the ends of the suture mustbe straight for ease of passage of the suture between the cannula andthe needle.

[0200] It is preferable that the suture being used have distinctmarkings to give an enhanced visual indication of the movement of thesuture. Different types and colors of markings along the length of thesuture will indicate how much suture has been advanced. It is preferredthat the suture have distinct markings at the beginning and terminalends of the suture, which could indicate the length of the suture whichhas been advanced.

[0201] If the meniscal tear is large, the repair operation should beginat the anterior portion of the tear. After the placement of the anteriorsuture, it will be easier to work along the anterior joint line to theposterior part of the tear. The medial meniscus is repaired with theknee in near extension or slight flexion. The lateral meniscus isrepaired with the knee in 45° to 90° flexion.

[0202] In a further modification of the invention, a suture passer maybe formed in a modular fashion so that a variety of different cannulascan be attached to its handle. These cannulas may be blunt (in themanner shown in FIGS. 1-3, 6, 7A, 7B, 14-23, 27A, 27B and 29-31) orsharply pointed, and they may be pre-formed straight (in the mannershown in FIGS. 1-3, 6, 7A, 7B, 14-23, 27A and 29-31) or already curved.

[0203] More particularly, and looking now at FIGS. 32-43, a modularsuture passer 100 is shown. Suture passer 100 generally comprises acannula 200 and a handle 300. Cannula 200 and handle 300 are configuredfor releasable locked engagement with one another.

[0204] More particularly, and still looking now at FIGS. 32-43, cannula200 comprises an elongated tubular member 202 and a thin, outwardlyextending radial fin 204. Fin 204 is attached to tubular member 202adjacent to the tubular member's proximal end 206 (see FIGS. 36, 38 and40).

[0205] Tubular member 202 may be formed out of a single piece of tubingif desired. Alternatively, it may be formed out of a plurality ofconcentric tubes so as to increase the rigidity of tubular member 202,e.g., to assist in penetrating tough tissue. In the specific embodimentshown in FIGS. 32-43, tubular member 202 is shown formed out of threeconcentric tubes 202A, 202B and 202C (see FIGS. 40 and 42). The innerdiameter of tube 202C is selected so as to engage the outer diameter oftube 202B, and the inner diameter of tube 202B is selected so as toengage the outer diameter of tube 202A. In addition, tube 202A is sizedso as to have the longest length, tube 202C is sized so as to have theshortest length, and tube 202B is sized so as to have an intermediatelength. The proximal ends of tubes 202A, 202B and 202C are aligned withone another so that tube 202B projects out of tube 202C and tube 202Aprojects out of tube 202B, and then the resulting structure is securedin place by welding or some other suitable process. It will beappreciated that a cannula 200 comprising the foregoing structure willbe quite strong.

[0206] The cannula's fin 204 comprises a main portion 208 and a tabportion 210 (see FIGS. 36, 38, 40 and 41).

[0207] Main portion 208 has a proximal edge 212 (see FIG. 40) which issubstantially aligned with the proximal end 206 of the cannula's tubularmember 202. Main portion 208 also has a bottom edge 214 which is spacedfrom the outer surface of tubular member 202 by a distance which isslightly less than the height of handle 300 (see FIG. 36). Main portion208 also has a distal edge 216 (see FIG. 40) which extends between themain portion's bottom edge 214 and the outer surface of tubular member202.

[0208] Tab portion 210 extends centrally and proximally from proximaledge 212 of the fin's main portion 208 (see FIG. 40). Tab portion 210 islocated in the same plane as main portion 208 (see FIG. 41) and ispreferably generally rectangular in shape, although other tab shapes mayalso be used without departure from the present invention. Tab portion210 includes an upper tab projection 218 (see FIG. 40) which projectsupwardly out of the tab portion's upper edge 220, and a lower tabprojection 222 which projects downwardly out of the tab portion's loweredge 224. Upper tab projection 218 defines an upper, distally-facing tabshoulder 226, and lower tab projection 222 defines a lower,distally-facing tab shoulder 230. Tab projections 218 and 222 arelocated between the proximal edge 212 of the fin's main portion 208 andthe proximal edge 232 of tab portion 210 (see FIG. 40). Tab shoulders226 and 230 are aligned with one another.

[0209] Looking next at FIGS. 32-39 and 39A, handle 300 comprises a firstsuture guide 302 and a second suture guide 304.

[0210] First suture guide 302 includes an eyelet 306 (see FIGS. 32 and33). A passageway 308 is provided to permit a length of suture (notshown in FIGS. 32-39 and 39A) to be slid transversely into eyelet 306.

[0211] Still looking now at FIGS. 32-39 and 39A, second suture guide 304comprises a generally semi-cylindrical member extending upwardly out ofthe handle's top side, between the handle's distal upper surface 310(see FIGS. 32-34) and its proximal upper surface 312. An axial bore 314(see FIGS. 36 and 38) extends longitudinally through second suture guide304. A top slot 316 (see FIGS. 32-34 and 36) extends down into secondsuture guide 304, transverse to the longitudinal axis of the handle. Aright side slot 318 (see FIGS. 33 and 36) extends between the secondsuture guide's distal end 320 and its top slot 316. A left side slot 322(see FIG. 32) extends between the second suture guide's proximal end 324and its top slot 316. Top slot 316, right side slot 318 and left sideslot 322 effectively bifurcate second suture guide 304 into a pair ofclosely-spaced, oppositely-extending fingers. These fingers can beconsidered to be somewhat analogous to the fingers 14-16 shown in FIGS.7A and 7B and described above. In view of the foregoing construction, alength of suture (not shown in FIGS. 32-39 and 39A) may be alignedparallel to the second suture guide's top slot 316, then dropped intothe top slot, and thereafter rotated 90° into the right side slot 318and 900 into the left side slot 322, so that the suture enters theinterior bore 314 of second suture guide 304.

[0212] Still looking now at FIGS. 32-39 and 39A, handle 300 alsocomprises a first bore 326 (see FIGS. 36 and 38) which extendsproximally and axially from the distal end of the handle toward theproximal end of the handle. First bore 326 includes a stop 327 (seeFIGS. 36 and 38) at its proximal end. First bore 326 is sized so as tobe able to receive the proximal portion of a cannula's tubular member202. First bore 326 is positioned so that when the cannula's tubularmember 202 is received in the handle's first bore 326, the central lumenof the tubular member will open onto the handle's distal upper surface310, between first suture guide 302 and second suture guide 304 (seeFIG. 36).

[0213] A vertical slot 328 (see FIGS. 35-37, 37A, 38, 39 and 39A)extends downwardly from first bore 326. Vertical slot 328 opens on thehandle's bottom surface 330 (see FIG. 36), and is sized to receive themain portion 208 of a fin 204 when a cannula 200 is mounted to handle300.

[0214] Still looking now at FIGS. 32-39 and 39A, a snap lock 332 (seeFIGS. 35-37, 37A, 38, 39 and 39A) is formed at the proximal end ofvertical slot 328. Snap lock 332 comprises a cavity 333 formed in handle300 immediately proximal to slot 328 (see FIGS. 35-37, 37A and 38).Cavity 333 is sized to receive the tab portion 210 of a fin 204 when acannula 200 is mounted to handle 300. The right sidewall of cavity 333comprises a proximally-extending continuation 334 (see FIGS. 37A and39A) of the right sidewall of vertical slot 328. Continuation 334 has alength substantially equal to the distance between the proximal edge 212of the cannula's main fin portion 208 and the distally-facing tabshoulders 226 and 230 of the cannula's tab portion 210 (see FIG. 40).The left sidewall of cavity 333 comprises an outward tapering 336 (seeFIGS. 37A and 39A) of the left sidewall of vertical slot 328.

[0215] Snap lock 332 also comprises a sloping upper sidewall projection338 (see FIGS. 36 and 38) extending inwardly into cavity 333 from thecontinuation 334 of the right sidewall of vertical slot 328, and asloping lower sidewall projection 340 (see FIGS. 37, 38 and 39A)extending inwardly into cavity 333 from the same continuation 334. Uppersidewall projection 338 defines an upper, proximally-facing sidewallshoulder 342 (see FIG. 38) and lower sidewall projection 340 defines alower, proximally-facing sidewall shoulder 344 (see FIGS. 37A, 38 and39A). Upper sidewall shoulder 342 is aligned with lower sidewallshoulder 344.

[0216] Upper and lower sidewall projections 338 and 340 are located suchthat as the tab portion 210 of a given cannula 200 enters the handle'scavity 333, the cannula's upper and lower tab projections 218 and 222will snap over and lockingly engage the handle's upper and lowersidewall projections 338 and 340 when the cannula is fully inserted intothe handle's first bore 328. In particular, when the assembly is in thislocked condition, the cannula's distally-facing upper tab shoulder 226will engage the handle's proximally-facing upper sidewall shoulder 342,and the cannula's distally-facing lower tab shoulder 230 will engage thehandle's proximally-facing lower sidewall shoulder 344 (see FIG. 36).

[0217] When a given cannula 200 has been mounted to the handle 300 inthe foregoing manner, rotational movement of the cannula relative to thehandle is precluded by the engagement of the cannula's main fin portion208 with the sidewalls of the handle's slot 328. In addition, axialmovement of the cannula relative to the handle is precluded (i) in theproximal direction by the engagement of the proximal end 206 of thecannula 200 with the stop 327 located at the proximal end of thehandle's first bore 326, and (ii) in the distal direction by theengagement of the cannula's two distally-facing tab shoulders 226 and230 with the handle's two proximally-facing sidewall shoulders 342 and344.

[0218] The handle of the modular suture passer 100 also includes meansfor releasing a cannula from its locking engagement with the handle.More particularly, and still looking now at FIGS. 32-39 and 39A, asecond longitudinal bore 348 (see FIGS. 36, 37, 37A, 38, 39 and 39A)extends between the proximal end 350 (see FIG. 36) of cavity 333 to theproximal end 352 (see FIGS. 36 and 38) of handle 300. Second bore 348includes a distal portion 354 (see FIGS. 36 and 38) communicating withcavity 333, an enlarged intermediate portion 356, and a proximal portion358 opening on the handle's proximal end 352. A proximally-facingannular shoulder 360 (see FIGS. 36 and 38) is formed at the intersectionof the bore's distal portion 354 with its intermediate portion 356, anda distally-facing annular shoulder 362 is formed at the intersection ofthe bore's proximal portion 358 with its intermediate portion 356. Thebore's distal portion 354 is sized so that the proximalmost portion ofcannula tab 210 may be contained therein (see FIG. 36).

[0219] A release rod 364 (see FIGS. 36, 37, 37A, 38, 39 and 39A) isslidably disposed in second bore 348. More particularly, release rod 364comprises a distal portion 366 (see FIGS. 36 and 38), an enlargedintermediate portion 368, and a proximal portion 370. A distally-facingannular shoulder 372 (see FIGS. 36 and 38) is formed at the intersectionof the rod's distal portion 366 and its intermediate portion 368, and aproximally-facing annular shoulder 374 is formed at the intersection ofthe rod's proximal portion 370 and its intermediate portion 368. Aspring 376 (see FIGS. 36 and 38) is captivated between bore shoulder 360and rod shoulder 372 so as to bias release rod 364 proximally (see FIGS.36 and 37). The engagement of rod shoulder 374 with bore shoulder 362limits proximal movement of release rod 364. Release rod 364 can beurged distally against the power of spring 376 by pressing on the rod'sproximal end 378 (see FIGS. 38 and 39). The distal end of release rod364 is beveled so as to form an end surface 380, a deflection surface382, and a drive surface 384 (see FIG. 37A).

[0220] To release a cannula 200 from handle 300, the proximal end 378(see FIGS. 36 and 37) of release rod 364 is forced distally so as tomove the release rod against the biasing force of spring 376. As releaserod 364 moves distally through handle bore 348, the release rod'sdeflection surface 382 (see FIG. 37A) will engage the proximal edge 232(see FIG. 40) of the cannula's tab portion 210 and deflect the tabportion 210 laterally so as to disengage the cannula's distally-facingtab shoulders 226 and 230 (see FIG. 40) from the housing'sproximally-facing sidewall shoulders 342 and 344 (see FIGS. 36 and 38).As release rod 364 continues to move distally through handle bore 348,the release rod's drive surface 384 (see FIG. 37A) will engage thecannula's proximal edge 232 (see FIG. 40), whereby the entire cannulawill be driven distally so that the cannula's two tab projections 218and 222 will clear the housing's two sidewall projections 338 and 340(see FIGS. 38, 39 and 39A). This will unlock the cannula from thehandle. Cannula 200 may thereafter be manually withdrawn from the handleby pulling the cannula in a distal direction.

[0221] Thus, it will be seen that a variety of different cannulas 200can be releasably attached to the handle 300. These cannulas can beblunt or sharply pointed, and they may be straight or curved, asrequired for a particular surgical procedure.

[0222] For example, a straight, sharply pointed cannula 200 is shown inFIGS. 32-43. Preferably, the pointed distal end of this cannula isformed by cutting the distal end of the cannula at a first, relativelysharp angle so as to form a sharp penetrating edge at 270 (see FIGS. 40,42 and 43), and then at a second, somewhat less severe angle so as toform a shallower tapering edge at 272. The cannula is preferably bluntedor rounded off at 274 (see FIGS. 42 and 43) so as to minimize thepossibility of damaging a suture during a tissue piercing operation, aswill hereinafter be discussed in further detail.

[0223] FIGS. 44 to 49 exemplify some of the other cannula configurationswhich may be utilized with handle 300. Specifically, these exemplaryconfigurations include a curved, sharply pointed cannula 200 (FIG. 44);another curved, sharply pointed cannula 200 (FIG. 45); still anothercurved, sharply pointed cannula 200 (FIG. 46); a “corkscrew”, sharplypointed cannula 200 (FIG. 47); a straight, blunt cannula 200 (FIG. 48);and a curved, blunt cannula 200 (FIG. 49). If desired, a reinforcingtube 202D (see FIGS. 45, 46, 47 and 49) can be added to the tubularmember 202 so as to further strengthen the tube against undesirablebending during tissue penetration.

[0224] Still other possible cannula configurations will be well known tothose skilled in the art.

[0225] It is anticipated that a surgeon will select a particular cannula200 depending on the particular surgical procedure which is to becarried out. For example, if the surgical procedure of FIGS. 14-26 orthe surgical procedure of FIGS. 27A, 27B and 28-31 is to be carried out,the surgeon might select the straight, blunt cannula of FIG. 48 or thestraight, sharply pointed cannula of FIGS. 40-43.

[0226] It will also be appreciated that modular suture passer 100 can beused in many different ways, in the context of many different surgicalprocedures, to pass a length of suture through tissue. For example,FIGS. 50-52 illustrate one possible way in which a straight, sharplypointed cannula 200 might be used to pass suture through a piece oftissue 500.

[0227] More particularly, and looking now at FIG. 50, a length of suture400 may be attached to the suture passer 100 by threading the suturethrough the suture passer's proximal guide member 304, through itscannula 200 and then back around its distal suture guide 302. This willallow the surgeon to adequately control the two ends of the sutureduring the tissue penetration operation.

[0228] The pointed distal end of the suture passer's cannula 200 is thendriven into and through the piece of tissue 500 (see FIG. 51). As thisoccurs, the suture extending out of the cannula's sharp distal tip willbe forced against the blunt heel 274 (see FIG. 43) of the cannula. Thecannula's blunt heel 274 will support the suture during tissuepenetration and prevent the cannula from cutting or otherwise damagingthe suture as the suture is carried through the tissue. Then the loop ofsuture residing at the far side of tissue 500 may be grasped by anothertool (not shown), one or both of the suture ends freed from the suturepasser 100, and suture passer 100 withdrawn from tissue 500 (see FIG.52). At this point the suture will have been passed through tissue 500,with a loop of suture positioned on one side of the tissue and the twofree suture ends positioned on the other side of the tissue.

[0229] FIGS. 53-55 illustrate how a simple stitch can be establishedacross two pieces of tissue using the present invention. Moreparticularly, a length of suture 400 is first loaded onto suture passer100 by feeding one end 400A of the suture into the suture passer'scannula 200. Suture end 400A is left sitting within the length ofcannula 200. Suture length 400B is loaded onto the suture passer'sproximal suture guide 304. The intermediate portion of suture 400 willextend along the handle's distal upper surface 310. Then the distal endof the suture passer's cannula 200 is forced through two pieces oftissue 500A and 500B until the distal end of the cannula exits thetissue. Next, the surgeon urges suture 400 distally through the cannulauntil suture end 400A exits the tip of the cannula (see FIG. 53). Thenthe suture passer is withdrawn from tissue 500A and 500B, paying out thesuture as it goes, so that suture 400 extends through both pieces oftissue (see FIG. 54). Next, suture 400 is withdrawn from the suturepasser and suture ends 400A and 400B are tied off into a knot (see FIG.55).

[0230] FIGS. 56-58 illustrate how a suture loop can be passed across twopieces of tissue using the present invention. More particularly, alength of suture 400 is first loaded onto suture passer 100 by feedingone end 400A of the suture into the suture passer's cannula 200. Sutureend 400A is extended all the way out the distal end of the cannula (seeFIG. 56). Suture end 400A is then brought back to the suture passer'shandle, so that the length of the suture will engage the blunted needleheel 274 as it exits from the cannula (see FIG. 57). Alternatively,suture end 400A could be left dangling until the force of tissuepenetration brings suture end 400A back against the blunted needle heel274. Suture length 400B is loaded onto the suture passer's proximalsuture guide 304. The intermediate portion of suture 400 will extendalong the handle's distal upper surface 310. Then the distal end of thesuture passer's cannula 200 is forced through two pieces of tissue 500Aand 500B until the distal end of the cannula exits the tissue. As thisoccurs, the suture will be carried through the tissue so that a loop ofsuture will reside on the far side of the tissue (see FIG. 58). Then thesuture passer is withdrawn from tissue 500A and 500B, paying out thesuture as it goes, so that both suture ends 400A and 400B will reside onthe near side of the tissue, with a loop of suture remaining on the farside of the tissue.

[0231] FIGS. 59-61 illustrate two different ways a folded suture loopcan be passed across two pieces of tissue using the present invention.More particularly, a portion of suture (i.e., either the two suture ends400A and 400B, or the intermediate portion of suture extending betweenthe two suture ends 400A and 400B) is placed inside the cannula 200 (seeFIG. 59). Then the cannula is inserted through tissue 500A and 500B sothat the distal end of the cannula emerges on the far side of thetissue. Next, the portion of suture previously held in the cannula(i.e., either the two suture ends 400A and 400B, or the intermediateportion of suture extending between the two suture ends 400A and 400B)is pushed outside the distal end of the cannula (see FIG. 60). Finally,the cannula is withdrawn from the tissue, leaving a loop of tissueresiding on one side of the tissue and the two suture ends residing onthe other side of the tissue (see FIG. 61).

[0232] FIGS. 62-64 illustrate how a simple stitch can be converted to amattress stitch with a suture loop using the present invention. Moreparticularly, a loop of suture 402 is first positioned on the far sideof the tissue using the technique of FIGS. 56-58, and a single strand ofsuture 404 is passed through the tissue using the technique of FIGS. 53and 54 (see FIG. 62). Then the end of suture 404 is drawn through theloop of suture 402 (see FIG. 63). Finally, the loop of suture 402 iswithdrawn back through tissue 500A, 500B, carrying the strand of suture404 with it (see FIG. 64).

[0233] Referring next to FIGS. 65-67, another embodiment of theinvention is shown which may be formed consistent with many of theprinciples described above. This further embodiment also provides manyadditional new features, in addition to sharing and refining features ofthe foregoing embodiments. The embodiment shown in FIGS. 65-67 isbelieved to be particularly advantageous in various shoulder surgeryrepairs such as a Bankart repair and a rotator cuff repair, and otherarthroscopic and laparoscopic procedures.

[0234] More particularly, a suture passer 600 is shown which generallycomprises an elongated cannula 602 and a handle 604. Cannula 602 andhandle 604 are not shown as being configured for releasable lockedengagement with one another, although they may be if the same should bedesired.

[0235] Cannula 602 comprises a hollow tubular member 606 that may beformed out of a single piece of tubing if desired. Alternatively, asshown in FIG. 71 and discussed in more detail below, the cannula 602 maybe formed out of a plurality of concentric tubes so as to increase therigidity of cannula 602, e.g. to assist in penetrating tough tissue.

[0236] Still referring now to FIGS. 65-67, handle 604 comprises acannula connector 608 and a proximal suture guide 610. Notably absentfrom this and other embodiments of the present invention is a proximalspool for delivering suture or thread-like material to the cannula, suchas the spool disclosed in U.S. Pat. No. 3,840,017, issued Oct. 8, 1974to Violante for SURGICAL INSTRUMENT. The construction of the presentinvention is significant because it permits surgeons to feed single,multiple or differently-sized strands of suture (and/or various tools,as will be discussed in detail below) unemcumbered into second sutureguide 610.

[0237] Suture passer 600 includes an entrance 612 for introducing sutureinto the cannula 602. More particularly, with this embodiment of theinvention, cannula connector 608 can be configured so as to leave theproximal end of cannula 602 exposed, such that suture entrance 612comprises the proximal end of cannula 602; alternatively, cannulaconnector 608 can also be configured so as to provide a body around theproximal end of cannula 602, and suture entrance 612 can be defined bythe body of the cannula connector 608. In either case, suture entrance612 is configured so as to aid surgeons in observing the feeding ofsuture (and/or tools) into the proximal end of cannula 602. To this end,the entrance 612 is oriented and/or configured so as to be oblique tothe suture axis when the suture is received in the cannula 602. Thisoblique entrance feature is especially helpful when the suture passer600 is in use such that the entrance 612 is positioned at an awkwardlocation for the surgeon. For example, when in use, the suture passer600 may be positioned relatively parallel to, and at a chest-high levelrelative to, the standing surgeon. This positioning makes it difficultfor the surgeon to observe and feed suture into cannula 602, since thesurgeon is effectively oriented transverse to the axis of cannula 602.The oblique entrance 612 enhances visibility of the entrance 612 andreduces some of the difficulties associated with locating and feedingsuture into cannula 602.

[0238] Proximal suture guide 610 includes a boss 614 upstanding from thehandle 604. The boss 614 has an interior bore 616 for receiving suture.As with the earlier embodiments, to aid in feeding suture into theproximal suture guide 610, the boss 614 terminates distally of theproximal end 618 of the handle 604. Accordingly, the handle provides aproximal upper surface 620. This stepped entry into the proximal sutureguide 610 facilitates passage of suture into the proximal suture guide610. The stepped proximal upper surface 620 aids in locating theentrance 622 of proximal suture guide 610, so as to facilitateintroducing suture into the guide's interior bore 616.

[0239] This embodiment of the suture passer refines the stepped-entryfeature with readily-visible entrances into the proximal suture guide610. Each entrance 622 and 624 of the boss 614 occurs on surfaces 626and 628, respectively, that are oblique to the axis of the interior bore616. The surface 626, and entrance 622 thereon, enhance the ability of asurgeon to observe and advance suture through the interior bore 616. Thesurface 628, and entrance 624 thereon, enhance the ability of a surgeonto advance suture through the cannula 602, as will be described in moredetail below.

[0240] Cannula connector 608 and proximal suture guide 610 define a gap630 therebetween. The handle 604 provides a top surface 632, foradvancing suture, corresponding to the gap 630. The gap 630 is optimizedso as to provide the surgeon with as much exposure to the suture aspossible on the top surface 632, while limiting the amount of suturethat is not sufficiently supported between suture entrance 612 andproximal suture guide 610. If the suture is not sufficiently supportedby these elements, the suture may buckle or skid sideways. The gap 630,preferably, ranges between about ⅜ and about 3½ inches in length,depending on the characteristics of the suture being used with the tool.

[0241] In addition to an optimized gap 630, surface 628 (and entrance624 thereon) enhance the ability of a surgeon to advance suture alongthe top surface 632 of the handle 604. This is because the obliquesurface 628 exposes more of the suture exiting the interior bore 616 forcontact with the surgeon's thumb or forefinger than if the surface 628were set at a right angle to the top surface 632. This feature affordsthe surgeon greater contact, and hence control, of the suture whileadvancing the suture through cannula 602.

[0242] Referring now to FIG. 67, the invention also enhances sutureadvancement and control with a shaped handle. This body shapefacilitates gripping the handle 604 with the thumb and middle finger.The shape also aids in maintaining the orientation of the handle 604 sothat the suture is readily accessible for advancement. The shape alsoprovides for positive orientation of the suture passer 600 with respectto the meniscus or other tissue to be repaired. This orientation featureis especially helpful where the cannula attached to the handle 604 isshaped or curved in a particular manner, such as those cannulas shown inFIGS. 44-49. Although the triangular handle shape shown in FIG. 67 amplyprovides these benefits, the invention may also incorporate other handleshapes that promote these benefits.

[0243] The suture passer 600, as with earlier embodiments, providesfacile suture advancement because the suture and cannula are located onthe top surface of the handle, not aligned with the central axis of thehandle. As a result, suture may be threaded into the suture passer 600more readily and is more accessible once threaded. This is especiallytrue in light of the optimized gap 630 and specially-configuredentrances 612, 622 and 624.

[0244] In one form of the invention, the invention employs a straight,sharply pointed cannula 602. Referring also to FIG. 43, preferably, thepointed distal end of the cannula is formed by cutting the distal end ofthe cannula at a first, relatively sharp angle so as to form a sharppenetrating edge 634, and then at a second, somewhat less severe angleso as to form a shallower tapering edge 636. The cannula is preferablyblunted or rounded off at its heel 638 so as to minimize the possibilityof damaging a suture during a tissue-piercing operation, as discussedabove in connection with the blunt heel 274 shown in FIG. 43. This bluntheel feature allows the surgeon to drive the cannula, out of whichsuture is advanced, into hard tissue without damaging the suture.

[0245] In addition to providing for passing and advancing single ormultiple sutures, the invention also provides for retaining one or moresuture strands. Retaining one or more suture strands allows a surgeon topass a selected one of multiple suture strands while maintaining theother suture strand(s).

[0246] Referring next to FIG. 68, a first embodiment of a sutureretainer 640 is shown. In this embodiment of the invention, the sutureretainer 640 is in the form of an aperture 642 that receives suturetherethrough. When the suture S is under tension, because it is drawnthrough the aperture 642, the suture rubs against the handle 604 and isrestrained from freely running through the cannula 602.

[0247] Referring next to FIG. 69, a second embodiment of the sutureretainer 640 is shown. In this embodiment of the invention, the sutureretainer 640 is in the form of a notch 644 in the handle 604 thatreceives and cleats suture. When the suture S is under tension, it isdrawn into the notch 644, more firmly cleating and restraining thesuture from freely running through the cannula 602.

[0248] Referring next to FIG. 70, a third embodiment of the sutureretainer 640 is shown. In this embodiment of the invention, the sutureretainer 640 is in the form of a grommet 646 mounted on the handle 604that receives and cleats suture. When the suture S is under tension, thesuture is restrained from freely running through the cannula 602.

[0249] As noted above, cannula 602 may comprise a single piece oftubing. Alternatively, cannula 602 may comprise a plurality ofconcentric tubes so as to increase the rigidity of the cannula, in amanner similar to the embodiment shown in FIGS. 40 and 42. Moreparticularly, and looking now at FIG. 71, tubular member 606 is shownformed out of three concentric tubes 606A, 606B and 606C. The innerdiameter of tube 606C is selected so as to engage the outer diameter oftube 606B, and the inner diameter of tube 606B is selected so as toengage the outer diameter of tube 606A. In addition, tube 606A is sizedso as to have the longest length, tube 606C is sized so as to have theshortest length, and tube 606B is sized so as to have an intermediatelength. The proximal ends of tubes 606A, 606B and 606C are aligned withone another so that tube 606B projects out of tube 606C and tube 606Aprojects out of tube 606B, and then the resulting structure is securedin place by welding or some other suitable process.

[0250] It will be appreciated that a cannula 602 comprising theforegoing structure will be quite strong. The stepped constructionincreases cannula strength without increasing the size of the distalportion of the cannula. And because this stepped constructionsignificantly enhances cannula strength, the cannula may be fairly longyet strong. This aids in performing arthroscopic surgical procedures. Inorder to access damaged areas arthroscopically, surgeons often mustadvance tools to relatively remote locations within the body. To do so,surgeons need sufficiently long cannulas to reach damaged areas. Thepresent stepped cannula provides a surgeon with a sufficiently long, yetstrong, cannula to reach damaged areas.

[0251] In addition to passing one or more sutures through tissue, thesuture passer 600 also may be used in combination with various tools.

[0252] Referring now to FIGS. 72-75, the suture passer 600 may be usedin conjunction with a loop retriever 700. As shown in FIGS. 72 and 73,the loop retriever 700 may include a handle 702 secured to a shaft 704,with the shaft terminating in a distal loop 706. The shaft 704 ispreferably constructed from flexible wire or fine hypodermic tubing, andloop 706 is preferably constructed from flexible stainless steel wire ora superelastic material such as Nitinol.

[0253] The gap 630 between cannula entrance 612 and the proximal sutureguide 610 provides sufficient access for inserting the loop 706 andshaft 704 into the cannula 602. The gap 630 is optimally configured sothat the loop 706 may be retained in the cannula 602, as shown FIG. 74,allowing the cannula 602 to be driven through tissue with minimalprofile. The gap 630 is also optimally configured so that, once thecannula 602 is positioned, the loop 706 of the loop retriever 700 may beadvanced out of the cannula 602 so that it expands, as shown in FIG. 75,in anticipation of receiving suture. Once suture is received within theloop, the loop retriever 700 may be retracted back into the cannula 602so as to bind the suture to the suture passer. In this respect it willbe appreciated that the cannula's blunt heel 638 will avoid cutting thesuture as the suture is pulled into the cannula.

[0254] Referring next to FIGS. 76-79, the invention also may be usedwith a hook retriever 708. As shown in FIGS. 76 and 77, the hookretriever 708 may include a handle 710 secured to a shaft 712, with theshaft terminating in a distal hook 714. The shaft 712 is preferablyconstructed from flexible wire or fine hypodermic tubing, and hook 714is preferably constructed from flexible stainless steel wire.Alternatively, shaft 712 and hook 714 may be formed out of asuperelastic material such as Nitinol or the like.

[0255] The gap 630 between the cannula entrance 612 and the proximalsuture guide 610 provides sufficient access for inserting the hook 714and shaft 712 into the cannula 602. The gap 630 is optimally configuredso that the hook 714 of the hook retriever 708 may be withdrawn into thecannula 602, as shown in FIG. 78, so that the cannula 602 may beadvanced smoothly into tissue and located proximate to a suture to beretrieved. Once properly positioned, the hook retriever 708 may beadvanced out of the cannula 602 so that it expands, as shown in FIG. 77,for grappling a suture. Once suture is grappled, hook 714 may bewithdrawn back into cannula 602 so as to capture the suture to the tool.Again, it will be appreciated that the cannula's blunt heel 638 willavoid cutting the suture as the suture is pulled into the cannula.

[0256] If desired, handle 702 (and/or handle 710) might include a lockfeature for releasably locking the loop retriever (and/or the hoolretriever) relative to handle 602.

[0257] It should also be appreciated that with the embodiment of FIGS.72-75, the loop retriever 700 may be loaded into suture passer 600 sothat shaft 704 extends through both cannula 602 and proximal sutureguide 610, and so that handle 702 sits proximal to proximal suture guide610; and with the embodiment of FIGS. 76-79, the hook retriever 708 maybe loaded onto suture passer 600 so that shaft 712 extends through bothcannula 602 and proximal suture guide 610, and so that handle 710 sitsproximal to proximal suture guide 610.

[0258] Referring next to FIGS. 80-82, an alternative form of suturepasser-and-hook retriever tool 900 is shown. The suture passer portionof the tool includes a handle (not shown), preferably similar to thehandle 604 described above, and a cannula 602 mounted on the handle. Asleeve 902 is slidingly received in the bore 648 of the cannula 602, andthe distal end of cannula 602 includes a slot 650.

[0259] The suture passer-and-hook retriever tool 900 also includes ahook retriever 904 fixed relative to the handle and cannula 602. Thehook retriever 904 includes a shaft 906 terminating in a distal hook908. Shaft 906 is bent at an angle intermediate its length. Hookretriever 904 is flexible, and is preferably constructed from asuperelastic material such as Nitinol.

[0260] The sleeve 902 has a bore 910 that receives shaft 906. The sleeve902 is configured to slide relative to the cannula 602 between distal(FIGS. 80 and 81) and proximal (FIG. 82) positions. When the sleeve 902is in its distal position, the hook 908 of the hook retriever 904 issubstantially retained in the passage 648 of the cannula 602 so that thecannula 602 may be advanced smoothly into tissue and located proximateto a suture which is to be retrieved. Once the cannula 602 is properlypositioned relative to the target suture, the sleeve 902 may bearticulated into its proximal position, as shown in FIG. 82, so that thehook 908 springs outwardly, through cannula slot 650, for capturing asuture. Once a suture is captured, the sleeve 902 may be articulatedback into its distal position, thereby urging the hook 908 back into thepassage 648 so as to bind a suture to the tool. Again, by formingcannula 602 with a blunt heel 638, cutting of the suture will be avoidedas the suture is captured to the cannula.

[0261] The foregoing description of the preferred embodiments of theinvention has been presented for the purposes of illustration anddescription. It is not intended to be exhaustive or to limit theinvention to the precise forms disclosed. Many modifications andvariations are possible in light of the above teachings and areconsidered to be within the scope of the present invention.

What is claimed is:
 1. A cannula having a proximal end, a distal end,and a passage therethrough, comprising a plurality of hollow cylindersthat are interconnected.
 2. The cannula of claim 1, wherein the proximalone of adjoining cylinders is more rigid than the distal one of saidadjoining cylinders.
 3. The cannula of claim 1, wherein: the proximalone of two adjoining cylinders has an inner diameter; and the distal oneof said two adjoining cylinders has an outer diameter; said innerdiameter being sized to engage said outer diameter.
 4. The cannula ofclaim 1, said cylinders being welded together.
 5. The cannula of claim1, wherein the distal one of two adjoining cylinders is longer than theproximal one of said two adjoining cylinders.
 6. The cannula of claim 1,wherein said cannula is sufficiently long such that said distal end ofsaid cannula may be located in an internal body cavity when saidproximal end of said cannula is located outside of the body.
 7. Anapparatus for receiving and passing one or more sutures, one or moretools, and combinations thereof, comprising: a handle having a proximalend and a distal end; and a cannula mounted on said distal end of saidhandle; wherein said proximal end of said handle is configured toreceive one or more sutures for passage into said cannula.
 8. Theapparatus of claim 7, wherein said handle excludes a spool forcontaining suture.
 9. An apparatus for receiving and passing one or moresutures, one or more tools, and combinations thereof, comprising: ahandle; and a suture guide, having a suture entrance, mounted on saidhandle; wherein said suture entrance is observable from a transverseprojection thereof.
 10. The apparatus of claim 9, said suture guidehaving an interior bore that extends through a surface, said surfacedefining said suture entrance; wherein said surface extends at anoblique angle with respect to said interior bore.
 11. The apparatus ofclaim 9, said suture guide having a second suture entrance which isobservable from a transverse projection thereof.
 12. The apparatus ofclaim 11, said suture guide having an interior bore that extends througha surface, defining said second suture entrance; wherein said surfacedefines an oblique angle with respect to said interior bore.
 13. Theapparatus of claim 9, further comprising: a cannula, having an entrance,mounted on said handle; wherein said cannula entrance is observable froma transverse projection thereof.
 14. The apparatus of claim 13, whereinsaid cannula entrance extends at an oblique angle with respect to thelongitudinal axis of said handle.
 15. An apparatus for receiving andpassing one or more sutures, one or more tools, and combinationsthereof, comprising: a handle having a first proximal end; a sutureguide, having a second proximal end, mounted on said handle; whereinsaid second proximal end is distal of said first proximal end.
 16. Anapparatus for receiving and passing one or more sutures, one or moretools, and combinations thereof, comprising: a handle; a cannula mountedon said handle; and a proximal suture guide mounted on said handle; saidcannula and said proximal suture guide defining a gap therebetween;wherein said gap is optimized to provide maximum suture exposure withlimited suture buckling during advancement of the suture.
 17. Theapparatus of claim 16, wherein said gap ranges from about ⅜ to about 3½inches.
 18. An apparatus for receiving and passing one or more sutures,one or more tools, and combinations thereof, comprising: a handle havinga shape that facilitates orientation thereof.
 19. The apparatus of claim18, wherein a transverse cross-section of said handle, relative to asuture or tool advancement direction, is generally triangular.
 20. Anapparatus for receiving and passing one or more sutures, one or moretools, and combinations thereof, comprising: a handle; and a cannulamounted on said handle; said handle having a surface for slidinglyadvancing suture into said cannula; wherein said cannula is aligned withsaid surface.
 21. The apparatus of claim 20, wherein advancing suture isachieved with a thumb or finger.
 22. The apparatus of claim 20, saidhandle having a first axis and said cannula having a second axis;wherein said first axis is offset from said second axis.
 23. Anapparatus for receiving and passing one or more sutures, one or moretools, and combinations thereof, comprising: a cannula having a distalend; wherein at least a portion of said distal end is configured todrive a suture against tissue without severing the suture.
 24. Theapparatus of claim 23, said cannula having a passage; wherein saiddistal end defines an oblique angle relative to said passage, with adistal sharp tip and a blunt proximal heel; said blunt proximal heeldefining said at least a portion.
 25. An apparatus for receiving andpassing one or more sutures, one or more tools, and combinationsthereof, comprising: a handle including a suture retainer.
 26. Theapparatus of claim 25, said suture retainer comprising a bore extendingthrough said handle for receiving suture.
 27. The apparatus of claim 25,said suture retainer comprising a notch formed in said handle forfrictionally engaging suture.
 28. The apparatus of claim 25, said sutureretainer comprising a grommet mounted to said handle for receivingsuture.
 29. An apparatus for receiving and passing one or more sutures,one or more tools, and combinations thereof, comprising: a handle; and acannula, configured to receive the one or more tools, mounted on saidhandle.
 30. The apparatus of claim 29, further comprising: a proximalguide, for guiding the one or more sutures, one or more tools, andcombinations thereof into said cannula, mounted on said handle; saidcannula and said proximal guide defining a gap therebetween; whereinsaid gap is optimized to articulate the one or more tools betweenrespective retracted and advanced positions.
 31. The apparatus of claim30, wherein the one or more tools is a loop retriever; said gappermitting the loop retriever to be articulated from a retractedposition wherein said loop retriever is retained in said cannula, and anadvanced position wherein said loop retriever may receive suture. 32.The apparatus of claim 30, wherein the one or more tools is a hookretriever; said gap permitting the hook retriever to be articulated froma retracted position wherein said loop retriever is retained in saidcannula, and an advanced position wherein said hook retriever mayreceive suture.
 33. The apparatus of claim 29, including a sleeveslidable relative to said cannula between an open position and a closedposition; wherein, when said sleeve is in said closed position, aworking portion of one of the one or more tools is disabled and whensaid sleeve is in said open position, the working portion of one of theone or more tools is enabled.
 34. The apparatus of claim 29, including asleeve slidable relative to said cannula between an open position and aclosed position; wherein, when said sleeve is in said closed position, aworking portion of one of the one or more tools is generally alignedwith said cannula, and when said sleeve is in said open position, theworking portion of the one of the one or more tools is not aligned withsaid cannula.
 35. A suture retrieving tool comprising: a handle having adistal end and a proximal end; a cannula having a distal end and aproximal end, said proximal end of said cannula being attached to saiddistal end of said handle, and said cannula having a slot opening on itsdistal end and extending toward its proximal end; a hook retrieverhaving a distal end and a proximal end, said distal end being configuredin the shape of a hook, and said proximal end being attached to saiddistal end of said handle, said hook retriever having a bendintermediate of its distal and proximal ends; and a sleeve having adistal end and a proximal end, said sleeve being disposed around saidhook retriever and within said cannula, said sleeve being slidablyattached to said handle such that (1) said sleeve can be positioned in afirst retracted position wherein said distal end of said sleeve isdisposed proximal to said bend, such that said hook retriever can extendout said slot in said cannula, and (2) said sleeve can be positioned ina second extended position wherein said distal end of said sleeve isdisposed distal to said bend, such that said hook retriever will bewithdrawn inboard of said slot.